Robot-assisted distal pancreatectomy reduces blood loss and conversions but increases operative time and cost

This systematic review and meta-analysis compared robot-assisted distal pancreatectomy (RDP) with laparoscopic distal pancreatectomy (LDP) in patients undergoing distal pancreatectomy for pancreatic ductal adenocarcinoma and other indications. The analysis included 15790 patients from multiple studies, though the specific number of studies and their designs were not reported. The population consisted of patients undergoing distal pancreatectomy, but detailed demographic or clinical characteristics were not provided. The primary outcome was not specified; secondary outcomes included blood loss, conversion rate, unplanned splenectomy, operative time, postoperative morbidity, postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), infection, reintervention, mortality, length of stay, lymph node yield, R0 resection rate, and costs.

For blood loss, RDP was associated with a significant reduction, with a weighted mean difference (WMD) of -52.0 mL (p < 0.00001). Conversion rate was significantly lower with RDP (risk ratio [RR] 0.49, p < 0.00001), as was unplanned splenectomy (RR 0.59, p < 0.0001). However, operative time was significantly longer with RDP (WMD +24.06 min, p < 0.00001). Length of stay was shorter with RDP (WMD -0.57 days, p < 0.00001). Costs were higher with RDP, but there was substantial heterogeneity, and no effect size was reported.

Postoperative morbidity, POPF, PPH, infection, reintervention, and mortality were comparable between RDP and LDP, with no significant differences reported. Lymph node yield appeared higher with LDP in overall and PDAC cohorts, but this was not significant in sensitivity analysis. R0 resection rate was comparable between groups.

Safety and tolerability were not reported in detail. Adverse events, serious adverse events, and discontinuations were not reported. The analysis did not provide specific adverse event rates.

Compared to prior landmark studies, these findings align with earlier meta-analyses suggesting that RDP offers advantages in reducing blood loss and conversions but at the cost of longer operative time and higher expense. The comparable rates of postoperative complications and mortality are consistent with previous evidence.

Key methodological limitations include the lack of reported study design details, potential heterogeneity among included studies, and the fact that the analysis combines observational and randomized studies, which limits causal inference. The certainty of evidence was not reported, and the learning curve effect for RDP was suggested as likely but not proven.

Clinically, RDP appears to reduce blood loss, conversions, and unplanned splenectomy, which may be beneficial in high-risk or complex resections. However, the longer operative time and higher costs warrant consideration. The comparable postoperative outcomes suggest that RDP does not compromise safety. Selective use of RDP in appropriate patients is supported, but cost-effectiveness requires further study.

Remaining questions include the impact of the learning curve on outcomes, long-term oncologic results, and cost-effectiveness in different healthcare settings. Further randomized controlled trials with standardized protocols are needed to confirm these findings.